Frequently Asked Questions

Frequently Asked Questions

What are the differences between medical documentation, medical record, and charting?

“Medical documentation” refers to the notes and documents that health care workers add to the medical record (the complete collection of all the documents that form a complete chronological health history of a particular patient). Charting is the process in which health care workers record their observations and findings. The charting itself then becomes part of the medical documentation that is included in the medical record.

What is the best way to correct a mistake made during charting?

Draw a single line through the error so it remains legible. Then write the correct information and note the error according to facility policy, along with the date and your initial.

How can I ensure that I am doing good medical documentation?

Review your charting and evaluate whether it is complete, concise, factual, and legible; includes the patient’s name and identifying number; uses correct spelling; is not duplicative; and uses approved abbreviations only.

What is meant by the term “chief complaint”?

Many people view the word “complaint” in a negative way, but in medicine, it merely means what the patient is concerned about that brought him or her to seek medical care.

May I choose which method of charting I wish to use, such as SOAP or Charting by Exception?

No, the method of charting is defined by the health care facility. For example, SOAP notes used by one person would have little effect on continuity of care and problem solving. Also, Charting by Exception requires a well-designed designation of what is normal and what is abnormal. To prevent chaos and to provide consistency, all health care workers need to follow the same format.